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1/14. pneumocystis carinii pneumonia presenting as a fever of unknown origin in a patient without AIDS.

    pneumocystis carinii pneumonia (PCP) remains an opportunistic infection that causes substantial morbidity and mortality in patients who have impaired immune function. PCP in patients who do not have AIDS usually manifests in a more fulminant manner than in patients with AIDS. In recent years, PCP has been reported increasingly in patients with connective tissue disorders. The role of corticosteroids in inducing PCP is well established in humans and animals, though information is currently lacking about the exact mechanism of induction, frequency, dosage, and duration of corticosteroid therapy that predisposes the development of PCP across a variety of patient groups. Until earlier diagnosis and a better understanding of who is at risk are readily available, health care providers need to consider the diagnosis of PCP early in the clinical course of any patient who receives systemic steroid therapy. We report a case of PCP in a patient who took oral steroid treatment for 2 months for suspected connective tissue disorder. The patient presented with a fever of unknown origin. The case is unusual because the patient's serial chest x-ray and gallium scan yielded normal findings and no suggestive respiratory signs or symptoms were found. The only suggestive finding was a consistently elevated serum lactate dehydrogenase level. The diagnosis was established by the identification of Pneumocystic carinii in bronchoalveolar lavage fluid.
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2/14. Cavitary pneumonia in an AIDS patient caused by an unusual bordetella bronchiseptica variant producing reduced amounts of pertactin and other major antigens.

    Although bordetella bronchiseptica can infect and colonize immunocompromised humans, its role as a primary pathogen in pneumonia and other respiratory processes affecting those patients remains controversial. A case of cavitary pneumonia caused by B. bronchiseptica in an AIDS patient is presented, and the basis of the seemingly enhanced pathogenic potential of this isolate (designated 814) is investigated. B. bronchiseptica was the only microorganism recovered from sputum, bronchoalveolar lavage fluid, and samples taken through the protected brush catheter. Unlike previous work reporting the involvement of B. bronchiseptica in cases of pneumonia, antibiotic treatment selected on the basis of in vitro antibacterial activity resulted in clearance of the infection and resolution of the pulmonary infiltrate. Although isolate 814 produced reduced amounts of several major antigens including at least one Bvg-activated factor (pertactin), the molecular basis of this deficiency was found to be BvgAS independent since the defect persisted after the bvgAS locus of isolate 814 was replaced with a wild-type bvgAS allele. Despite its prominent phenotype, isolate 814 displayed only a modest yet a significant deficiency in its ability to colonize the respiratory tracts of immunocompetent rats at an early time point. Interestingly, the antibody response elicited by isolate 814 in these animals was almost undetectable. We propose that isolate 814 may be more virulent in immunocompromised patients due, at least in part, to its innate ability to produce low amounts of immunogenic factors which may be required at only normal levels for the interaction of this pathogen with its immunocompetent natural hosts.
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3/14. isospora belli infection: observation of unicellular cysts in mesenteric lymphoid tissues of a Brazilian patient with AIDS and animal inoculation.

    We describe the finding of unizoic cysts of isospora belli in lymphoid tissues of a Brazilian patient with AIDS, and discuss the possibilities of their drug resistance, they being the cause of relapses, and of being an indication for the existence of intermediary or paratenic animal hosts.
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4/14. VapB-positive rhodococcus equi infection in an HIV-infected patient in japan.

    rhodococcus equi, a bacterium present in soil, is a common cause of pneumonia in foals. This organism has been recognized as an opportunistic pathogen in humans, typically causing infection in immunocompromised hosts such as HIV-infected patients and organ transplant recipients. However, human infection with R. equi has not been reported in japan except in a case involving a laboratory worker. We report the first human case of VapB-positive R. equi pneumonia, which involved an HIV-infected patient living in an urban area in japan. The patient was treated successfully with 450 mg rifampicin and 600 mg tosufloxacin, even though his CD4 lymphocyte count at the time of diagnosis was 10/microl. The patient's dogs were suspected in the epidemiology of this infection, but unfortunately we could not isolate the organism from canine-associated specimens in this case. R. equi infections in companion animals have been thought to be very rare, but they may be increasing in dogs. Therefore, further epidemiological research may clarify the prevalence of R. equi infection and the factors predisposing dogs to this infection.
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5/14. A comprehensive review of disseminated salmonella arizona infection with an illustrative case presentation.

    salmonella arizona is known to cause infection in reptiles and other animals. Disseminated human infection is rare, except in the setting of a deficient immune system. The following is a unique account of disseminated infection including pericardial involvement. Unusual features include nonreptile vector transmission and eastern seaboard (rather than southwestern) locale. A comprehensive literature review of disseminated S arizona infections is presented describing the types of infection, sources of exposure, underlying conditions, locale, treatments, and outcomes.
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6/14. Infections due to rhodococcus equi in three HIV-infected patients: microbiological findings and antibiotic susceptibility.

    Infections of rhodococcus equi, a well-known pathogen in animals which causes cavitated pneumonia similar to that caused by mycobacteria, were studied in three HIV-infected patients. This microorganism was isolated in the bronchoalveolar washings of two patients and in the sputum of the third. In two patients, Rh. equi represented the first clinical opportunistic manifestation of HIV disease. One patient died of concomitant Pneumocystis infection. The eradication of the microorganism occurred in two out of three patients. It was found that no isolates were resistant to erythromycin, claritromycin, rifampin, vancomycin, teicoplanin, imipenem, gentamycin or azithromycin (MIC values < or = 0.1 microgram/ml). Moreover, the quinolones (ciprofloxacin and ofloxacin) were found to be less effective, whereas neither the beta-lactam antibiotics nor chloramphenicol were effective therapy for this microrganism. At least two antimicrobial agents should be given contemporaneously to treat these infections for a period of up to several months. Our results suggest that the combinations erythromycin rifampin or imipenem teicoplanin are the most effective treatments in Rh. equi infections.
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7/14. rhodococcus equi infection in HIV-positive patients: report of 5 cases and literature overview.

    The importance of rhodococcus equi infection, an uncommon human pathogen that almost exclusively affects immunocompromised hosts, has greatly increased following the advent of acquired immune deficiency syndrome (AIDS) epidemics. Until the present time, 38 cases of R. equi infection have been described in human immunodeficiency virus (HIV)-infected patients; we now report a further five personal cases. R. equi was acquired via respiratory exposure to animals in less than half of the patients, and caused invasive pulmonary infection (91%), bacteraemia and sometimes bloodstream dissemination. R. equi was easily cultured from sputum or blood, but its diagnosis was often difficult due to microbiological and clinical similarities with other pathogens. The persistence of the micro-organism inside macrophages and its high tissular load represent the major limitation to an effective treatment. Several antibiotics are active in vitro, but their efficacy in vivo depends on macrophage uptake and/or bactericidal activity. Treatment should start with at least two intravenous bactericidal antibiotics for 3-4 weeks, and then continue with oral therapy for a period of up to several months with at least two intracellularly active drugs. Surgical resection of the lesions may be beneficial in selected cases.
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8/14. Retinal toxicity of high dose intravitreal ganciclovir.

    BACKGROUND: Intravitreal administration of ganciclovir has been used to treat cytomegalovirus (CMV) retinitis in patients with acquired immune deficiency syndrome (AIDS) who are unable to tolerate systemic antiviral therapy. Although retinal toxicity from intravitreal ganciclovir has been observed in animal experiments, to our knowledge, retinal toxicity from intravitreal ganciclovir has not been reported in humans. methods: A case of inadvertent intravitreous injection of a high dose of ganciclovir (40 mg/0.1 ml) for CMV retinitis in a patient with AIDS is presented. RESULTS: Despite immediate intervention with vitreous surgery, permanent retinal damage and visual loss developed. Clinical observations and photographic documentation are provided. CONCLUSION: Retinal toxicity can occur from a high-dose intravitreal ganciclovir injection. This toxicity may result from the high alkaline nature of this preparation, from osmotic damage, or from a direct effect of the concentrated ganciclovir.
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9/14. rhodococcus equi infection: a cause of cavitary pulmonary disease in immuno-compromised patients.

    rhodococcus equi is a facultatively-aerobic, gram-positive and intracellular bacteria that causes pulmonary and disseminated infections in immuno-compromised patients. It is a common agent that causes pneumonia in farm animals and only rarely is transmitted to man. I report a case of pneumonia caused by this agent in a patient with AIDS who had been misdiagnosed as tuberculosis and treated as such for five months before the correct diagnosis was made. The diagnosis should be suspected on clinical and radiologic grounds as treatment is considerably different from other opportunistic pathogens in AIDS.
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10/14. bacillus piliformis infection (Tyzzer's disease) in a patient infected with hiv-1: confirmation with 16S ribosomal rna sequence analysis.

    bacillus piliformis is a long, rod-shaped bacterium that has never been grown in cell-free medium and whose taxonomic classification is uncertain. B. piliformis is the causative agent of Tyzzer's disease, which is frequently reported in laboratory, wild, and domesticated animals. The spectrum and severity of this disease is wide in animals. Although many infections are rapidly fatal, subclinical infections are also common. To date, there have been no reports of B. piliformis infection in human beings, although elevated antibody levels have been reported in pregnant women. We describe the first case of human B. piliformis infection, in a man with hiv-1 infection and chronic, localized, crusted verrucous lesions. The diagnosis was confirmed by ribosomal rna sequencing. The spectrum of organisms leading to infection and the spectrum of diseases caused by these organisms continue to expand, as new infections are identified and as patients with hiv-1 live longer with more severe immune suppression. The extreme difficulty in culturing B. piliformis and the lack of clinical and histopathologic experience with this organism in human beings mean that B. piliformis is potentially another infectious agent to be considered in human beings. Also, when an infectious organism is a strong clinical consideration, silver stains may be of use when results of routine bacterial staining are negative.
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